Recurring concern
Failure to acknowledge and act on family and carer safety concerns in patient care
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Request correctionFirst reported 6 Sep 2013•Latest report 24 Jun 2026
What this concern includes
Includes failures within patient-care processes to receive, acknowledge, recognise, record, investigate, escalate or act on safety concerns raised by parents, families, carers or next of kin, including concerns about a child's condition or care and concerns raised during hospital or community care.
Not included
- Excludes generic communication, information-sharing or documentation deficiencies where no family or carer safety concern about patient care is involved.
- Excludes routine dissatisfaction or complaints without a material patient-safety concern.
- Excludes concerns raised by employees, clinicians or other professionals when the unsafe condition is not the handling of a family or carer concern.
- Excludes failures confined to informing families or carers about care when they did not themselves raise a safety concern.
- Excludes complaints-handling failures in non-healthcare settings or care-setting-specific processes where an existing narrower concern provides the more faithful boundary.
- Reports
- 19
- Individual concerns
- 22
- Date range
- 2013–2026
- Stated actions
- 32
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to follow up family concerns about a patient's condition
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Complete the commissioned case review to identify system improvements and examine its findings for wider learning.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Update the discharge lounge SOP on patient capacity, deteriorating-patient management, and exclusion criteria for unsuitable patients.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Require the discharge lounge team to record full observations electronically and use SBAR escalation for deterioration or medical emergencies.
Stated by Worcestershire Acute Hospitals NHS Trust
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Action
Implement Martha’s Rule across the Trust as an alternative escalation pathway for patients, relatives, and staff concerned about a patient’s condition.
Stated by Worcestershire Acute Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The patient was in the discharge lounge before transfer, not the PDU.
Stated by Worcestershire Acute Hospitals NHS Trust
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Concerns raised1
Failure to respond appropriately to family concerns and communicate the patient’s treatment wishes
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate family concerns to assessing clinicians
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Maintain the updated Mental Health Liaison Service procedure requiring carer involvement, communication, feedback and provision of a carers’ information leaflet.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure to act on family-provided information indicating heightened and escalating risk
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Deliver a two-day CRAM training event for Urgent Mental Health Helpline staff to improve risk recognition, risk curiosity and co-produced care and risk management planning.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Introduce visual prompts at every call station and workstation directing staff to arrange Rapid Response assessment within four hours when risk is concerning.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Update the Duty Standard Operating Procedure to require same-day routine referral action and careful consideration of family members’ information.
Stated by Vita Health Group Ltd
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Action
Deliver a reflective Duty Team session sharing case learning and the resulting Standard Operating Procedure changes.
Stated by Vita Health Group Ltd
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
An urgent referral was not indicated because reported deterioration lacked evidence of dynamic risk, risky behaviour, suicide planning or intent.
Stated by Vita Health Group Ltd
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Concerns raised1
Failure to recognise and act on parents’ ongoing concerns about children on hospital wards
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
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Action
Maintain a Learning Disabilities and Autism policy with emergency admission guidance and requirements for carer involvement.
Stated by Royal Surrey NHS Foundation Trust -
Action
Implement Martha’s Rule across adult and paediatric services, addressing its three delivery metrics for patient, family, carer and staff escalation.
Stated by Royal Surrey NHS Foundation Trust -
Action
Continue rolling out Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce.
Stated by Department of Health and Social Care
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Action
Support rollout of Martha’s Rule and engage with NHS England as pilot data emerge.
Stated by Royal College of Paediatrics and Child Health -
Action
Collaborate with NHS England and the Royal College of Nursing to develop a single national Paediatric Early Warning System for England.
Stated by Royal College of Paediatrics and Child Health -
Action
Publish interim guidance on mandatory learning disability and autism training for providers and CQC staff.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Provision of nursing care and access to learning disability liaison nurses fall outside the respondent’s authority.
Stated by Royal College of Paediatrics and Child Health
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Concerns raised1
Failure to listen to and sufficiently investigate concerns and complaints raised by next of kin
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Conduct quarterly anonymous Family Satisfaction Surveys and use their findings in governance-led service improvements.
Stated by The Children's Trust -
Action
Operate a monthly senior-leader Family Forum, document themes, and monitor agreed actions.
Stated by The Children's Trust -
Action
Create a Clinical Governance Department and a senior role championing children’s and families’ experiences.
Stated by The Children's Trust
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Action
Revise the complaints policy and process to address gaps and align with national best practice.
Stated by The Children's Trust -
Action
Introduce a modified escalation procedure enabling families to request a second opinion or further care review.
Stated by The Children's Trust
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Concerns raised1
Inadequate systems and processes for responding to urgent complaints and concerns
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Operate the revised Complaints Procedure, including an escalation process.
Stated by Betsi Cadwaladr University LHB -
Action
Review incident and complaint processes and create an integrated framework covering incidents, complaints and mortality.
Stated by Betsi Cadwaladr University LHB -
Action
Roll out the Call 4 Concern service to general hospital sites, providing patients and families access to urgent clinical support.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to act on family concerns about medication access after leaving home
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Support patients and carers who raise risk concerns by contacting patients, exploring concerns, and managing them accordingly.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to give adequate weight to concerns from carers and family familiar with a patient's presentation
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Trial a Carers Passport and supporting documentation prompting carers to describe patients’ individual needs and pain expressions.
Stated by Sandwell and West Birmingham Hospitals NHS Trust -
Action
Deliver patient experience and communication education emphasizing carers’ involvement, expertise, and contribution to care and outcomes.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
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Concerns raised1
Failure to act on carers’ health and safety concerns
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026